2026 Drug List (pharmacy formulary) — Coverage Criteria
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This document is BCBSNM's 2026 pharmacy drug list describing covered prescription drugs, tier placements, specialty drug handling, and member/provider processes for coverage, prior authorization, step therapy, and exceptions. It applies to members and prescribing providers using BCBSNM pharmacy benefits.
No material clinical or coverage changes in this revision.
Coverage criteria and formulary controls
General Coverage Criteria
Covered drugs are those listed on the drug list and are subject to plan-level rules and limits.
See Drug List online (MyPrime.com or bcbsnm.com) for the most current entries.
Tier placement may vary by plan; verify benefit-specific cost share via MyPrime.com or the member ID card.
PA/ST indicators appear in the Special Requirements column of each drug line; exception/decision timeframes follow payer rules.
A QL indicator on a drug line specifies the maximum amount allowed (e.g., tablets or mL per X days).
General formulary coverage guidance
Coverage and restrictions are indicated on each drug line and determine coverage adjudication.
Consult the specific drug line for product‑level administrative controls and limits.
Hepatitis C antiviral coverage (PA & QL)
Coverage and administrative stance for hepatitis C direct‑acting antivirals are specified per product.
Clinical eligibility criteria and treatment‑course specifics are not included in this excerpt; follow product line and PA instructions.
HIV therapy coverage notes
Antiretroviral agents (HIV) are listed with tier and dispensing limits where applicable.
If 'PA' appears on the line, prior authorization is required before dispensing.
Formulary entries with tier and requirements
Formulary coverage and any product constraints are listed on each drug line and must be met for coverage.
Providers should review the individual drug line for exact QL values, PA or SP designations.
Formulary coverage with utilization management
Certain drug groups have consistent utilization controls across multiple products.
See each insulin product line for tier placement and dispensing format.
Prescribers must obtain PA when 'PA' appears on the drug line.
Refer to the product line for exact QL and any PA requirement.
Formulary Listings and Controls
Each drug line shows the product, tier, and any utilization controls that must be satisfied for coverage.
Examples include PA+QL for oral solutions and specialty injectables (see specific lines).
Coverage with utilization controls
Formulary coverage is subject to the utilization controls shown on each drug line.
Follow the drug line and payer PA submission procedures when indicated.
General coverage logic
Coverage decisions rely on drug‑specific tiering and the Requirements/Limits recorded on the formulary line.
Examples: CIMZIA, ENTYVIO PEN, NUCALA and other biologics carry PA and QL and are routed to specialty pharmacy as indicated.
General formulary coverage conditions
Coverage of listed drugs is governed by the product tier and its stated Requirements/Limits. Covered when ALL of the following product‑level conditions are met:
Operational compliance with the Requirements/Limits column is required for coverage adjudication.
Drugs not shown on the list are not covered. Coverage is limited to medications listed on the BCBSNM drug list and is subject to the plan’s rules, FDA labeling, and evidence‑based guidelines. Non‑FDA‑approved drugs, repackaged medications, and certain compounded medications may not be covered; refer to member benefit materials or call the number on the ID card for exceptions and payment verification. Prior authorization requirements are indicated as 'PA' in the Special Requirements column for drugs that need approval before coverage. (See examples: EPCLUSA, HARVONI and other DAAs noted with PA.)
This excerpt does not include a standalone exclusion list. Absence of a drug or formulation from the printed lines in this extract does not itself establish coverage; drugs not listed on the official drug list are considered not covered unless otherwise authorized. For specific excluded categories (for example, some OTC equivalents or cosmetic uses), consult the full benefit plan materials and the complete drug list online.
Within the provided extract there are no explicit clinical exclusion statements enumerated. The document segment emphasizes per‑product controls (Drug Tier and Requirements/Limits such as PA, QL, SP, AC or ST) rather than listing conditions or patient populations that are categorically excluded. For any formal exclusion language, refer to the full drug list and member plan documents.
Coding and quantity-limit examples
| N/A | This excerpt does not list CPT/HCPCS/ICD-10 codes; it lists drug names, formulations, tiers, and requirement/limit annotations. |
| NDC/HCPCS not specified | Document lists many drug products but does not provide specific billing codes in these chunks. |
| NDC/HCPCS not specified | No explicit procedure, diagnosis, or billing codes (CPT/HCPCS/ICD-10/NDC) are listed in this document segment; only drug names, tiers, PA/QL/SP attributes are present. |
Prior authorization, step therapy, documentation, and denial risk
Prior authorization and exception timing
Prior authorization (PA) is required for certain drugs noted with 'PA' in the Special Requirements column; prescribers must submit PA requests via the number on the member ID card or provider portals and will receive a decision within three business days (standard) or within 24 hours for expedited reviews.
- PA is indicated next to products in the Special Requirements column (e.g., many specialty, antineoplastic, and inhaled agents).
- Exception/expedited review timelines: standard = 3 business days; expedited = 24 hours.
Prior authorization requirement (inhaled/specialty)
Obtain prior authorization before prescribing or dispensing inhaled and specialty inhalation agents listed with 'PA' and 'SP' (examples include ARIKAYCE, tobramycin nebulized solutions, TOBI PODHALER); failure to obtain PA may result in coverage denial.
- ARIKAYCE — Requirements/Limits = PA, QL (28 vials/28 days), SP.
- Tobramycin nebulized solutions and TOBI PODHALER — Requirements/Limits include PA, QL and SP.
PA required for certain hepatitis C treatments
Prior authorization is required for selected direct-acting hepatitis C antivirals marked 'PA' (e.g., EPCLUSA, HARVONI, SOVALDI, VOSEVI, MAVYRET); submit PA and adhere to the QL listed per product.
- EPCLUSA — Requirements/Limits = PA, QL (28 tablets/28 days), SP.
- HARVONI and other DAAs are listed with PA and product-specific QL.
Prior authorization required for select specialty/antineoplastic drugs
Many antineoplastic and specialty oral oncology agents are labeled PA and SP; prescribers must obtain prior authorization and follow specialty pharmacy requirements and QL to avoid claim denial.
- Examples: abiraterone (Zytiga) — PA, QL (120 tablets/30 days), SP.
- Numerous oncology agents have PA + QL + SP noted in Requirements/Limits.
PA required for listed products
Providers must obtain prior authorization for products annotated 'PA' next to the product line; many listed products require PA before dispensing.
- The formulary marks PA in the Requirements/Limits column for numerous drugs; claims may be denied without PA.
- PA applies across therapeutic classes including specialty injectables, oral oncology, and select endocrine/metabolic agents.
PA required for many specialty/oncology drugs
Numerous specialty and oncology drugs include 'Requirements/Limits = PA' and require prescriber-submitted prior authorization before dispensing; providers must follow PA processes to prevent denials.
- Examples throughout the formulary show PA flags for many high-cost specialty/oncology agents.
- Specific PA criteria are not provided in this excerpt; follow payer PA procedures.
PA required for select listed drugs
Prior authorization is required for select products flagged 'PA' in the list (examples include deflazacort formulations and budesonide oral suspension); obtain PA prior to dispensing to avoid coverage restriction or denial.
- Deflazacort (Emflaza) formulations — Requirements/Limits = PA, QL, SP for multiple strengths.
- Budesonide oral suspension (Eohilia) — Requirements/Limits = PA, QL (1800 mls/90 days).
Prior authorization required for select agents
When 'PA' appears in Requirements/Limits for specified agents (e.g., select metformin ER, MOUNJARO, semaglutide products), prescribers must submit prior authorization and respect the listed quantity limits.
- MOUNJARO — Requirements/Limits = PA, QL (4 pens/180 days for 2.5 mg; 4 pens/28 days for other strengths).
- OZEMPIC and semaglutide entries — Requirements/Limits = PA, QL (e.g., 1 pen/28 days for OZEMPIC).
Prior authorization requirement for listed specialty agents
Prior authorization is required for multiple specialty endocrine/metabolic agents marked 'PA'; providers must obtain PA before coverage is approved for these specialty agents.
- Examples: ACTHAR — Requirements/Limits = PA, SP; GALAFOLD — PA, QL (14 capsules/28 days), SP.
- Follow payer PA submission procedures for specialty endocrine/metabolic therapies.
Prior authorization required
Providers must obtain prior authorization for many listed drugs (PA flagged) and ensure any specialty injectables or select oral agents meet PA and QL requirements prior to dispensing.
- Specialty injectables and select oral agents are commonly annotated PA and QL; claims may be denied without PA.
- Check each drug line for PA, QL, and SP annotations before ordering/dispensing.
Prior authorization required for selected specialty and oral solution products
Prior authorization and quantity limits apply to several specialty oral solutions and high-cost oral products (e.g., QBRELIS lisinopril oral solution is PA with QL 2400 mL/30 days; REPATHA requires PA with QL 6 syringes/28 days); include QL and PA details in submissions.
- QBRELIS (lisinopril oral solution) — Requirements/Limits = PA, QL (2400 mls/30 days).
- REPATHA (evolocumab) — Requirements/Limits = PA, QL (6 syringes/28 days).
- TYVASO — Requirements/Limits = PA, QL (81.2 mls/28 days), SP.
PA required for listed specialty and selected agents
Prior authorization is required for many listed specialty agents; providers must obtain PA before dispensing those labeled 'PA' to avoid denial.
- Multiple PA-marked specialty products are present (e.g., ORENITRAM, TYVASO, UPTRAVI, VERQUVO, VYNDAMAX, NUCALA).
- Follow PA processes and include QL and SP details on requests.
Prior authorization required for specified drugs
Several listed products require prior authorization as indicated on each drug line (examples: NUCALA, TEZSPIRE, XOLAIR, TRIKAFTA, KALYDECO); submit PA and adhere to the stated quantity limits and specialty dispensing requirements.
- NUCALA — PA, QL (3 pens/28 days for 100 mg auto-injector), SP.
- TEZSPIRE — PA, QL (1 pen/28 days), SP.
- TRIKAFTA — PA, QL (56 packets/28 days or 84 tablets/28 days), SP.
PA required for specific specialty medications
Prior authorization is required for certain specialty medications annotated with 'PA' (examples include BYLVAY, CIMZIA, ENTYVIO PEN, GATTEX); obtain PA and follow specialty channel rules.
- BYLVAY — Requirements/Limits = PA, SP.
- CIMZIA — Requirements/Limits = PA, QL (4 syringes/28 days), SP.
- ENTYVIO PEN — Requirements/Limits = PA, QL (2 pens/28 days), SP.
PA + QL for biologics
Many biologic and specialty injectables are subject to PA and an associated quantity limit per dosing period (e.g., SKYRIZI, TREMFYA, OMVOH); include QL details in PA requests to ensure correct adjudication.
- SKYRIZI — Requirements/Limits = PA, QL (1 cartridge/56 days), SP.
- TREMFYA — Requirements/Limits = PA, QL (1 syringe/28 days), SP.
PA required for select drugs
Certain products require prior authorization as noted next to the product name (e.g., NUPLAZID, tasimelteon); prescribers must obtain PA before billing or dispensing these agents.
- NUPLAZID — Requirements/Limits = PA, QL (30 capsules/30 days).
- Tasimelteon (capsule and oral suspension) — Requirements/Limits = PA, QL (30 capsules/30 days; 158 mls/30 days), SP.
Step therapy exception process
Step therapy (ST) may require trial of a preferred first-line agent before coverage of ST-designated drugs; prescribers can submit an ST exception request via the number on the member's ID card.
- If the preferred first-line drug is not appropriate, prescribers may request a step therapy exception.
- Exception decisions follow the standard/expedited timelines (3 business days / 24 hours).
Step therapy note — ST indicators present but rules not detailed
This excerpt does not provide detailed step-therapy sequences; some products are marked 'ST' (e.g., AUVELITY, KERENDIA) or flagged SP/AC, but the specific prior-step requirements are in the full policy.
- AUVELITY and select antidepressant/antipsychotic entries show 'ST' in the list where applicable.
- Refer to the comprehensive policy for required prior trials and documentation.
Documentation required for PA and QL agents
Prescriptions for drugs with quantity limits (QL) or PA should include documentation supporting medical necessity and dosing consistent with the listed QL (examples: azithromycin QL 60 tablets/180 days; ARIKAYCE PA with QL 28 vials/28 days).
- Include indication, dose, and requested quantity/timeframe when submitting PA for QL agents.
- Examples: azithromycin = QL (60 tablets/180 days); ARIKAYCE = PA, QL (28 vials/28 days).
Submit PA documentation per payer process
When PA is required (PA noted in Requirements/Limits), providers must submit prior authorization documentation per payer procedures to obtain coverage; include indication, dosing schedule, and quantity information.
- Follow the payer's PA submission process (call the number on the member ID card or use provider portals).
- Supporting clinical information will be necessary for adjudication of PA requests.
PA and specialty pharmacy denial risk
Prior authorization denials or failure to use the specialty pharmacy channel for SP-designated products (e.g., many oncology and biologic agents) may lead to claim denials; prescribers must obtain PA and use specialty dispensing where required.
- Antineoplastics and many specialty agents are PA + SP — lack of PA or failure to use SP may cause denial.
- Specialty channel requirements are noted by 'SP' on product lines and should be followed.
Quantity limit denial risk — exceed QL at risk of denial
Exceeding quantity limits (QL) listed on product lines (e.g., linezolid suspension QL 600 mL/180 days; linezolid 600 mg tablets QL 56 tablets/180 days; vancomycin capsules QL 120 capsules/30 days) may trigger claim denial or require member payment for excess quantity.
- Linezolid for suspension — QL 600 mL/180 days; 600 mg tablets — QL 56 tablets/180 days.
- XIFAXAN 200 mg — QL 9 tablets/30 days; 550 mg — QL 126 tablets/365 days.
- Dispensing beyond DL/QL may result in member responsibility for full cost.
Prior Authorization required — confirm before dispensing
Claims for drugs marked 'PA' will be subject to prior authorization; failure to obtain PA when required may result in denial — verify the Requirements/Limits field on each drug line before dispensing.
- The formulary flags PA next to affected products; confirm PA status on the drug line.
- If PA is required and not obtained, the claim may deny.
Include QL and specialty info on PA/claim submissions
Include quantity-limit (QL) and specialty (SP) designations on PA/claim submissions — many products list QL (e.g., ORENITRAM 300 tablets/30 days; TYVASO 81.2 mL/28 days) and SP that affect adjudication and dispensing.
- ORENITRAM — Requirements/Limits = PA, QL (300 tablets/30 days), SP.
- TYVASO — Requirements/Limits = PA, QL (81.2 mls/28 days), SP.
- NUCALA — PA, QL (3 pens/28 days for 100 mg auto-injector), SP.
Specialty channel requirements — use SP when indicated
Specialty-designated products (SP) typically require specialty pharmacy dispensing; failure to use the specialty channel when indicated may result in coverage denial or claim rejection.
- SP annotation denotes specialty pharmacy handling is required for many biologics and high-cost agents.
- Examples: NUCALA, TREMFYA, SKYRIZI, many oncology and rare-disease products.
Dispensing beyond limits may incur member cost or legal limits
Dispensing quantities beyond listed dispensing limits or QL may make the member responsible for the full cost of the excess medication; for controlled substances state law may also prohibit coverage beyond limits.
- Dispensing beyond QL/DL can result in member financial responsibility.
- State laws may bar coverage for certain controlled substances dispensed beyond limits.
Initial therapy and administrative initiation rules
Initial therapy guidance
Formulary placement and initial dispensing constraints for initiating therapy.
Specific product QL/PA values are shown on each drug line; clinical PA criteria are not included in this excerpt.
Administrative initial-therapy rules
Administrative initial‑therapy rules direct the process for coverage when a PA or QL is present.
Clinical eligibility specifics for PA are not provided in this excerpt; follow payer PA submission instructions.
Initial therapy rules (per-product PA/QL)
Initial coverage for selected products is subject to the per‑product PA and QL shown on the Drug List.
Prescriber must request PA when initiating therapy.
Confirm exact QL on the Drug List prior to initial dispensing.
Titration pack coverage
Titration pack QL and PA are shown on the Drug List lines for those products.
Step therapy / initial therapy controls
Products annotated with 'ST' may require a trial of preferred alternatives prior to coverage.
Detailed step sequences and acceptable alternatives are defined in the full policy; not present in this excerpt.
Step therapy flags and table
| Drug / Class | ST Flag (Special Requirements) | Notes |
|---|---|---|
| General formulary - step therapy program | ||
| ST — indicated when present in Special Requirements | ||
| Exceptions: prescriber or member may request a step therapy exception via the number on the member's ID; decisions issued within 3 business days (standard) or 24 hours (expedited) |
| Example drug(s) | ST Flag | Policy note |
|---|---|---|
| Azithromycin (various formulations) | ||
| No ST indicated | ||
| Shown with QL (60 tablets/180 days) but no step-therapy sequence described in excerpt |
| Example drug(s) | ST Flag | Policy note |
|---|---|---|
| Darunavir / other oral antivirals | ||
| No ST indicated | ||
| Entries list PA and QL (e.g., darunavir QL entries) but no prior-step failure sequence is provided in this excerpt |
| Product | ST / SP Flag | Notes |
|---|---|---|
| PALFORZIA (multiple level packs) | ||
| SP (specialty) | ||
| Designated SP and listed by dose levels; step therapy requirements are not specified in these chunks |
| Agent / Class | AC Flag | Notes |
|---|---|---|
| Selected oral oncology agents (example: tamoxifen) | ||
| AC noted for some agents | ||
| AC flags appear (e.g., tamoxifen Requirements/Limits = AC) but specific step therapy rules are not provided in this segment |
| Product examples | AC / SP Flag | Notes |
|---|---|---|
| Deflazacort formulations (Emflaza) | ||
| PA, SP noted (entries also show QL) | ||
| Some contraceptives and selected therapies are flagged AC or SP indicating administrative/step edits or program controls must be met prior to coverage |
| Product | ST Flag | Notes |
|---|---|---|
| KERENDIA (finerenone) | ||
| ST noted in Requirements/Limits | ||
| KERENDIA is listed with QL (30 tablets/30 days) and marked ST indicating step therapy applies (detailed step criteria not in excerpt) |
| Product | ST Flag | Notes |
|---|---|---|
| AUVELITY (dextromethorphan HBr–bupropion HCl ER) | ||
| ST noted | ||
| AUVELITY is annotated with ST indicating step therapy requirements must be met prior to coverage per full policy; prescriber must document trials of preferred agents |
| Requirement | Prescriber action | Notes |
|---|---|---|
| Document trials of preferred agents (when ST applies) | ||
| Submit step therapy exception via the number on the member's ID card or provider portals | ||
| Exceptions are processed within three business days (standard) or 24 hours for expedited/urgent requests; prescriber documentation should support prior trials as defined in full policy |
Quantity limits (QL) by product — key-value list
Site-of-care and specialty pharmacy guidance
Definitions and flag glossary
Background and scope
Specialty drugs are high‑cost or complex therapies used to treat conditions such as hepatitis, hemophilia, multiple sclerosis, and rheumatoid arthritis. They may be oral, topical or injectable and some require administration by a health care professional; such products may be managed through specialty pharmacy channels or billed to the medical benefit rather than the pharmacy benefit. Review the drug line for any SP (specialty) designation or site‑of‑care notes which indicate specialty dispensing or medical‑benefit handling.
The extract contains no explicit ‘Not Medically Necessary’ (NMN) statements. While some agents or categories (for example, products with OTC equivalents or drugs used for cosmetic purposes) may be excluded under plan materials, this excerpt does not set out specific NMN determinations. Coverage decisions are governed by the drug list entries, their Drug Tier, and any listed Requirements/Limits (PA, QL, SP, ST) and by the member’s benefit plan documentation.
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